Provider Demographics
NPI:1972667806
Name:LOO, GRANT QUAN (DMD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:QUAN
Last Name:LOO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 BASTON RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2976
Mailing Address - Country:US
Mailing Address - Phone:706-868-1722
Mailing Address - Fax:706-868-9516
Practice Address - Street 1:224 BASTON RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-2976
Practice Address - Country:US
Practice Address - Phone:706-868-1722
Practice Address - Fax:706-868-9516
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA109621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice